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2 Front Cover Picture: Anthrophyllite asbestos, viewed through a scanning electron microscope. From Image contains materials that came originally from the United States Geological Survey, an agency of the United States Department of Interior. Sourced from Wikimedia Disclaimer: The Department of Labour has made every effort to ensure that the information contained in this publication is reliable, but makes no guarantee of its completeness. The Department may change the contents of this guideline at any time without notice. Crown copyright 2011 This material is Crown copyright unless otherwise stated and may be reproduced free of charge without requiring specific permission. This is subject to it being reproduced accurately and not being used in a derogatory manner or in a misleading context. The source and copyright status should be acknowledged. The permission to reproduce Crown copyright protected material does not extend to any material in this report that is identified as being the copyright of a third party. Published by the Department of Labour PO Box 3705, Wellington 6140, New Zealand March 2011 ISBN:

4 INTRODUCTION The Department of Labour s two Asbestos Registers - the Disease Register and the Exposure Register - have been in existence since When established, they had the following objectives: 1. to raise awareness of asbestos-related disease nationally; 2. to improve the radiological diagnosis of asbestos disease by using the ILO reference radiographs; 3. to confirm that pleural plaques is a disease and not just a marker for asbestos exposure; and 4. to reinforce the importance of patient support groups. The legacy of disease from working with and exposure to asbestos in New Zealand is continuing. Exposure is now largely confined to brake repairers, lino removers, demolition workers, carpenters, electrical, plumbing and building maintenance workers, and asbestos removal workers. Worldwide, asbestos exposure still occurs at a high level; and there are a number of lessons than can be learned as a result. Firstly, there continues to be a general lack of awareness of the effects of inhaling dust at work, regardless of the type of dust. Secondly, too great an emphasis has been put on whether or not dust is a danger to health. Concepts that cement dust is safe and silica dust is unsafe; or blue asbestos is worse than white asbestos, have distracted governments from the real issue of dirty workplace air. Today, this is recognised as a major problem, both in terms of respiratory and general health. However, its solutions are not complex. They involve putting in place good general and local exhaust ventilation, and providing comfortable and effective respiratory protection. While that sounds relatively simple, there needs to be a desire for clean workplace air. With a gradual reduction in cigarette smoking among the working population, the impact of dirty workplace air on respiratory health is likely to become clearer, with diseases such as welder s lung, asthma, and chronic obstructive pulmonary disease recognised more clearly for their relationship to work practices and procedures. Dr W I Glass (Convenor) Dr R Armstrong Dr D Jones Dr A Brant National Asbestos Medical Panel March

7 PART 1: ASBESTOS 1.1 What is Asbestos? Asbestos is a term used to describe naturally occurring fibrous hydrated silicates of which there are six common varieties. Figure 1 below shows the different types of asbestos. Asbestos Serpentine Group Amphibole Group Chrysotile (white) Actinolite Tremolite Anthophyllite Amosite (brown) Crocidolite (blue) Figure 1: Types of Asbestos Amosite (brown asbestos) and crocidolite (blue asbestos) have straight needlelike fibres which naturally split in their long axis producing very fine fibrils (thin fibres). In contrast, chrysotile (white asbestos) has softer curlier hair-like fibres, which makes them useful for weaving and have been used to make asbestos cloth for centuries. When these fibres are inhaled they behave in different ways in the lungs. Chrysotile (magnesium silicate) fibres slowly lose magnesium, which leaches into body fluids making the fibre more easily digested by scavenger cells (macrophages). This reduces the body burden of the asbestos dust, and has led to the view that white fibres are less harmful. Crocidolite (iron-sodium silicate) fibres are straight and rigid and can split longitudinally. They are more resistant to body fluids and can survive unchanged in the body for up to 40 years or more. The fine fibrils can migrate through the lung tissue to the lung lining (pleura). 7

8 Amosite (iron magnesium silicate) fibres are longer, making it useful for insulation. Again, the fibres remain unchanged in the body for years Asbestos awareness in New Zealand 1938 The introduction to the Report of the Interdepartmental Committee on Silicosis refers to asbestos as follows: In the working of asbestos the dust produced gives rise to a pulmonary condition known as asbestosis, which, although different in its character from silicosis, causes a disease similar in some respects to it. Free silica is not associated with asbestos, yet the fibres produce a deadly pulmonary disease In the Annual Report of the Department of Health Dr Garland, Director of the Division of Occupational Health, Notes: Asbestos is now being quarried in the Dominion, and the dust can be expected to cause a certain amount of lung damage unless proper precautions are taken Notification of occupational diseases introduced. No specific dentification of asbestos-related lung disease Occupational Health Notes on Diseases Arising from Occupation published by the Department of Health: The fibrosis of asbestos is diffuse there is some statistical evidence for an increased incidence of bronchogenic carcinoma A New Zealand standard is set for asbestos fibres in air Dr Copplestone, Assistant Director (Occupational Health) initiates a New Zealand asbestos survey Dr Allingham, who succeeded Dr Copplestone, reports on the survey: 207 workers surveyed. 101 workers x-rayed. 17 showed pleural changes (one case later confirmed as asbestosis) Environmental Dust Laboratory established to identify asbestos fibres in air Asbestos Regulations promulgated The allowable concentration for asbestos fibres (other than crocidolite fibres) was reduced from 2 fibres/ml to 1 fibre/ml. 8

9 Crocidolite remained at 0.2 fibres/ml over a 10-minute sampling period Jim Butterworth, Auckland Secretary, NZ Engineers Union, expresses concern about long-term effects of asbestos on workers at James Hardie factory Interim Report of Workers at James Hardie (unpublished) Kjellstrom T and Rennie F. Of 353 workers x-rayed, 53 showed parenchymal and/or pleural changes. An increasing percentage of abnormalities found over time since first exposure. Asbestos Regulations replace 1978 regulations. A New Zealand Gazette notice reduced air standard for crocidolite to 0.1 fibre/ml over 4 hours Relative Cancer Risks from Exposure to Different Asbestos Fibre Types. J. Keir Howard, NZ Medical Journal 97; In this review article, the point is made that: considerable amounts of crocidolite were used in the past, particularly in insulation, and as New Zealand did not restrict the use of the amphiboles until well after most industrialised nations had done so, the use of blue asbestos continued for longer in this country. Importation of blue and brown asbestos banned in New Zealand Asbestos Regulations 1983, Amendment No. 1, tightens provisions for medical examinations Thelma Bell, widow of asbestosis victim Clarrie, organises a public meeting in Christchurch. Barry Brown, Secretary of the South Island Labourers Union, arranges for Maevis Watson, Occupational Health Nurse and Associate Professor Bill Glass from the Otago Medical School, to interview ex-fletcher workers from the Mandeville Street plant. Cate Brett Christchurch Star highlights the tragedy of asbestos use Robin McKenzie, Engineer with NZED (New Zealand Electricity Department), is diagnosed as suffering from mesothelioma. In 1990, his lawyer took legal action against the Crown. Media coverage keeps up public concern. 9

10 1990 Review of Fletcher s Mandeville Street Factory (unpublished) Glass W.I. 103 workers contacted. 87 investigated. 47 cases of asbestos-related conditions (plus 7 probable cases). 12 deaths to date. Hon. Bill Birch, Minister of Labour, establishes the Asbestos Advisory Committee in October to report on all aspects of asbestos exposure in New Zealand Lung Cancer, Smoking and Exposure to Asbestos in New Zealand. Glass W.I; Kawachi I., Pearce N. Journal of Occupational Health Safety 7 (1). Case control studies based on NZ Cancer Registry showed that asbestos-related occupations were found to be associated with elevated risks of cancer in the lung, pleura and peritoneum. The risks of cancer in these three sites were highest among the group comprising machinery fitters, plumbers, welders, boilermakers, metal moulders, metal polishers and electricians. Report of the Asbestos Advisory Committee presented to the Minister in April and Minister decides to implement the recommendations following Cabinet approval in August. Tim Frederiksen establishes the Asbestos Victim and Support Group, which later became the Asbestos Disease Association of New Zealand In March, a National Asbestos Register was established (recommendation 4 of the Report). This Register was to be in two parts: Part 1 for those who had been exposed and Part 2 for those suffering from an asbestos-related disease. The Occupational Safety and Health Service of the Department of Labour was appointed to administer the registers. ECNZ (Electricity Corporation of New Zealand) combines with the Department of Labour to publicise asbestos hazards. An audit of floor sanders and work practices involving asbestosbacked vinyl sheeting in the Christchurch area was carried out by KD Sheat and published by OSH (Department of Labour). ACC lump sum entitlements for asbestos-related claims ceased The first Annual Report of the National Asbestos Registers confirms 199 cases of asbestos-related disease. 10

11 (March) Rights to initiate common law claims in regard to asbestosrelated conditions ceased. ECNZ establishes model asbestos surveillance programme of current and past employees. Secondary cases of asbestos disease found to occur in family members of asbestos workers whose only exposure was to dust, brought to the home from the workplace The second Annual Report reviews and confirms a total of 462 cases of asbestos-related diseases. Visit by Professor Margaret Becklake, International Asbestos Authority, to advise on registers Asbestos Exposure and Disease Notes for Medical Practitioners published by Department of Labour. 1995/96 The third Annual Report confirms 535 cases The Management of Asbestos in the Non-Occupational Environment published by Ministry of Health. 1996/97 The fourth Annual Report of the National Asbestos Register notes an increase in occurrence of mesothelioma cases The Asbestos Medical Panel published its first report based on a review of asbestos cement-exposed workers on the Exposure Register notifications were reviewed. A positive finding was a non-specific association between cumulative asbestos exposure and a questionnaire diagnosis of asthma Health and Safety in Employment (Asbestos) Regulations 1998 promulgated Visit by Professor Corbett McDonald and Professor Alison McDonald to advise on updated information on mesothelioma. Asbestos and the New Millennium published. Prepared by Lois Syret and Ed Grootegoed on behalf of The Asbestos Association of New Zealand Mesothelioma in New Zealand, the second study by the National Asbestos Medical Panel. Increased Mesothelioma Incidence in New Zealand. T Kjellstrom, P. Smartt. NZMJ, November. 11

12 Lung function changes in asbestos-exposed workers with pleural plaques, the third study by the National Asbestos Medical Panel Asbestos New Zealand 2001, Lois J Syret and A.H. Grootegoed. Occupational Safety and Health (Department of Labour) Review of Guidelines for the Management and Removal of Asbestos. Asbestos Exposure in New Zealand. Bill Glass, New Ethicals, August The New Zealand National Asbestos Registers 1992 to 2001, Lessons Learned. Presented at Asbestos Symposium Seoul National University, Korea by Bill Glass. The Epidemic of Asbestos-related Diseases in New Zealand. Int. J. Occup Environ Health 10.2 June 2004 Tord Kjellstrom Mortality and Morbidity in Asbestos Exposure in New Zealand: The Hidden Legacy of Asbestos Exposure. NZ Med J 117; 117: 1 P Smartt. 12

13 PART 2: REVIEW OF ASBESTOS-RELATED DISEASE NOTIFICATIONS 2.1 Summary This report reviews 1198 cases that were notified to the National Asbestos Medical Panel between March 1992 and July They include: 224 cases of mesothelioma 116 cases of lung cancer 269 cases of asbestosis 589 cases of pleural abnormalities. The number of lung cancer cases reported is roughly half of the number of mesothelioma cases. This suggests that the taking of a lung cancer history is still dominated by the smoking factor, and that occupational factors are downplayed. The transfer of asbestos from workers to the home is another emerging feature of asbestos-related disease in New Zealand. Family members are presenting with pleural changes or, rarely and tragically, mesothelioma. Mesothelioma notifications remain high, reflecting exposure in the 1960s and 1970s, and this trend is likely to continue for some years to come. 13

14 2.2 Results Figure 2 shows the distribution of the four main diagnostic categories: lung cancer pleural disease asbestosis mesothelioma. Figure 2: Categories of Disease What is noticeable is that pleural disease is the main category, with lung cancer clearly under-represented when compared with mesothelioma. 14

15 Figure 3 looks at occupations for the total number of notified asbestos disease cases during the period. Figure 3: Notified Asbestos Disease by Occupation It is clear that carpenters, plumbers and electricians are together responsible for 67 percent of all cases. These all purpose construction workers are an occupational category at risk particularly because, unlike asbestos cement workers, they are not always seen as being at obvious risk. The non-occupational category refers to cases where an individual s exposure was not work-related. This includes all cases resulting from secondary or environmental exposure, such as children brought up in the home of an asbestos worker, and people who washed asbestos-contaminated clothes. The no known exposure category refers predominantly to mesothelioma cases where conclusive exposure histories were not available. (Note: the time delay is often years from exposure and has either been forgotten, never recognised, or not known by the surviving family member). 2.3 Mesothelioma Mesothelioma - a rare cancer of the pleural membranes on the surface of the lungs - is strongly related to asbestos exposure. The panel reviewed 224 cases of mesothelioma, of which: 215 were Caucasian 6 were Maori 3 were identified as Other 210 were males, 14 were females the mean age at diagnosis was 67 years (range 35-85) the mean number of years since first exposure was 45 (range 12-74) the mean exposure index was 178 (range 1-780) 15

16 there were 19 current smokers, 125 ex-smokers and 59 never-smokers (information for 21 cases was unavailable). Asbestos processors, plumbers/fitters/laggers, and carpenters/builders, accounted for over 60 percent of all registered cases. It has been noted that an asbestos exposure history may be lacking with mesothelioma cases. Our experience suggests that with patience and recognition of the range of likely exposures, it is often possible to obtain evidence of asbestos exposure. In one case the disease developed in a middle-aged woman living in a small rural town. It was revealed that as a teenager she had washed the clothes of an older brother who had been a railway workshop apprentice. Asbestos lagging was used in the repair and maintenance of the boilers, and apprentices were known to use asbestos in snowball fights. Figure 4: Distribution of Mesothelioma by Occupation 16

17 2.4 National Cancer Figures for Mesothelioma Figure 5: Number of Cases of Mesothelioma in New Zealand from 1954 to 2007 Over the period of 1954 to 2007, a total of 983 cases of mesothelioma have been registered. Figure 5 shows that the total number of cases continues to rise and in 2005 it exceeded 100 for the first time. However, in 2006 the total was 80, and 91 in Mesothelioma is very much a disease of old age as Table 7 illustrates, with over 50% of cases occurring to people aged 70 or over. Age Group Gender Total Male Female Under to to Total Table 7: Mesothelioma Occurrence by Age Range Of the 983 cases, 136 occurred to women and 837 to men. As women are seldom employed directly in the asbestos-exposed workplaces, their exposure could be as a result of secondary exposure to dust brought home from work on the hair and clothes of family members. 17

18 2.5 Lung Cancer Lung cancer is a cancer of some of the cells in parts of the lung, usually beginning in the lining of the airway. The panel reviewed a total of 116 cases of lung cancer, of which: 110 were Caucasian 4 were Maori 1 was from a Pacific Island 1 was identified as Other 114 were males, 2 were females the mean age at diagnosis was 69 (range 42-86) the mean number of years since first exposure was 46 (range 17-63) the mean exposure index was 165 (range ) there were 25 current smokers, 81 ex-smokers, 7 never smokers and 3 unknown. Lung cancers are classified according to the type of cell affected. Histological classification revealed 52 cases of squamous cell carcinoma, 29 adeno, 15 small cell, 4 undifferentiated, 1 bronchiolar-alveolar, 4 large cell and 11 cases where classification was not stated. In addition, the tumour sites were as follows: 46 upper lobe, 42 lower lobe, 11 middle lobe, and 17 not stated. The occupational distribution of lung cancer follows a similar pattern to both pleural plaques and asbestosis, in that plumbers, fitters, carpenters and asbestos processors account for most of the cases. See Figure 6: Distribution of Lung Cancer by Occupation. Figure 6: Distribution of Lung Cancer by Occupation 18

19 2.6 Asbestosis Asbestosis is a fibrotic or scarring disease of the lung tissue. The disease develops slowly over many years from initial exposure. It can continue to develop after exposure to asbestos has ceased. The panel reviewed a total of 269 cases of asbestosis, of which: 265 were Caucasian 2 were Maori 2 were from a Pacific Island 253 were males, 16 were females the mean age at diagnosis was 68 (range 37-86) the mean number of years since first exposure was 43 (range 15-71) the mean exposure index was 180 (range ) there were 21 current smokers, 192 ex-smokers and 49 never smokers (accurate smoking histories were not available in 7 cases) radiological changes showed 154 cases with pleural plaques and/or pleural thickening. Figure 7: Distribution of Asbestosis Notifications by Occupation 19

20 Figure 8: ILO Grading of Asbestosis Cases (n = 150) Of the 269 asbestosis cases, 150 were categorised by ILO classification, and others were categorised on the basis of CT, HRCT or pathology, where available. With the recent trend to use HRCT, categorisation by ILO classification is less frequently done Definition of Asbestosis used in the Register An important issue with this disease is what criteria constitute a diagnosis of asbestosis? The main point of discussion is the difference between a clinical diagnosis of asbestosis, and a diagnosis suitable for use in a national database where the inclusion of patients with early disease is desirable. The definition of Gilson a in his review of asbestosis-related lung conditions in the ILO encyclopaedia has been chosen by the panel and is as follows: (a) a history of significant exposure to asbestos dust rarely starting less than 10 years before examination; (b) radiological features consistent with basal fibrosis (1/0 and above, ILO 1980); (c) characteristic bilateral crepitations; and (d) lung function changes consistent with at least some features of the restrictive syndrome. Gilson notes not all criteria need to be met in all cases, but that (a) is essential, and (b) should be given greater weight than (c) or (d). However, occasionally (c) may be the sole sign. Further, he notes that although the restrictive syndrome is the most common pattern (about 40%), in about 10% of cases airway obstruction is the main feature, while in the remainder a mixed pattern is seen. a Gilson JC: Asbestosis, Encyclopaedia of Occupational Health and Safety, rd edition, vol 1 pp

21 Of the 269 asbestosis cases: all had a significant exposure history, with a mean exposure index of 180 (range ) mean latency was 42 years, with a range of years most cases had an ILO rating 1/1 or greater where this rating was used, although this criterion is now seldom used detailed clinical examination results were not always available from the records, thus the presence of crackles was not measurable lung function changes are recorded in the register based on the availability of data either from respiratory laboratories, respiratory physicians, or occupational health nurses additional information from HRCT scanning has led to the recognition of some cases of asbestosis not covered by the Gilson criteria. As noted, HRCT diagnosis is now the norm. The lung function test numbers in the report confirm the classical restrictive lung function pattern picture does not dominate, with obstructive, mixed, and normal patterns occurring. 2.7 Pleural Abnormalities Pleural abnormalities include pleural plaques, diffuse pleural thickening, chronic fibrosing pleuritis and pleural effusions. It does not include pleural disease occurring together with mesothelioma, lung cancer or asbestosis. Figure 9: Distribution of Pleural Abnormality Notifications by Occupation 21

22 Of the 589 cases reviewed: 577 were Caucasian 8 were Maori 4 were from Pacific Islands all but 10 were males the mean exposure index was 162 (range 6-708) there were 59 smokers, 349 ex-smokers and 148 never smokers (accurate smoking histories were not available in 35 cases). 2.8 Discussion Information recorded in the Disease Register under-estimates the total burden of asbestos-related disease in New Zealand. This is a consequence of the voluntary nature of the Register, lack of understanding of work as a factor in disease causation by the medical profession, and failure by the Cancer Registry to code occupation in their database. However, the Register continues to serve a useful purpose. There is now greater awareness of the work factor in disease than in 1992 when the Register was established. The Department of Labour now has greater commitment to the importance of occupational illnesses; the Accident Compensation Corporation employs a greater number of occupational doctors, and there are increasing numbers of occupational nurses and safety officers in the private sector. The Registers, part of the wider Notifiable Occupational Disease System (NODS) operated by the Department of Labour have, in the view of the medical panel, played an important part in encouraging these developments Pleural Plaques One of the aims of the medical panel was to confirm the view that pleural plaques were not just a marker of exposure, but represented a disease state. The Department of Labour publication Lung Function Changes in Asbestos Exposed Workers with Pleural Abnormalities in 2000 indicated a clear dose response pattern, including a reduction of FVC and FEV1 with increasing asbestos exposure, independent of smoking habit. Reference was made earlier to the impact of an asbestos-related occupation on the health of a worker s partner and children. Two cases of pleural plaques notified in the last few years illustrate two women developing widespread plaques in their early 70s. Their only exposure was to asbestos dust brought home on their husbands clothes which they washed. In one case the husband was an asbestos sprayer; the other, a carpenter Asbestosis The increasing use of HRCT has resulted in the identification of minor degrees of asbestosis often with few, if any, symptoms and no disability. It is possible that these individuals will have a better long-term outlook, although this is not yet established. 22

23 2.8.3 Lung cancer The contribution of occupational asbestos exposure to the causation of lung cancer is well recognised as being under-estimated, and over-attributed to smoking among workers exposed to asbestos. One approach to this issue is to determine the ratio between mesothelioma and lung cancer on the grounds that most mesotheliomas are diagnosed and the majority are regarded as being caused by asbestos exposure at work. Various estimates of such a ratio have been suggested and, as noted by Kjellstrom b can range from 1 to 10. Even if the lower ratio of 1:2 is taken based on the mesothelioma cases diagnosed over , for example some 1,594 cases of lung cancer due to asbestos exposure would have occurred, or approximately 145 a year. It is likely that this figure could be even higher Mesothelioma Reported cases of mesothelioma have continued to rise in New Zealand over the past decade as was shown in Figure 5, and based on the New Zealand Cancer Registry. It is of interest to note the mean exposure index for mesothelioma of as recorded by the panel - is not dissimilar to exposure indices for pleural plaques (162), lung cancer (162) and asbestosis (180). In other words, mesothelioma, like other asbestos-related conditions, is in general dose dependent Chronic Obstruction Pulmonary Diseases (COPD) and asbestos exposure These conditions are now being recorded if present in individuals with an asbestos-related disease, as well as in those asbestos-exposed workers who have no confirmed asbestos-related lung or pleural disease. Over the past years 33% of the 85 cases of asbestos-related disease also had COPD, 40% among cases of pleural plaques, 45% among asbestosis cases, 80% among lung cancer cases and 0% among cases of mesothelioma. In addition, ten cases that were referred to the Panel because of asbestos exposure but without classical asbestos-related conditions, had COPD. b Kjellstrom T: The Epidemic of Asbestos-Related Diseases in New Zealand. International Journal Occupational - Environmental Health 2004, 102 June 23

24 PART 3: NON-ASBESTOS OCCUPATIONAL RESPIRATORY DISEASE There has been little emphasis on the importance of occupational asthma, silicosis and work-related chronic obstructive respiratory disease in New Zealand until recent years. However, there is a historical base to non-asbestos occupational respiratory disease as referenced below: 1938 Silicosis: Report of Interdepartmental Committee, Bulletin No 57, Department of Scientific and Industrial Research, Wellington1. This report noted that since the 1915 Miners Phthisis Act, 1,576 miners had been granted pensions as a result of silicosis; of those, 1,508 were described as gold miners and 68 as coal miners. 1940s A record of tuberculosis morbidity in hospital nurses recorded in the book Challenge for Health by Dr F.S. McLean 2 showed a morbidity rate per 1,000 nursing staff which ranged from 8.9 to 20.3, averaging 16.5 over the years The Grey Valley Survey 3 in which Dr Francis de Hamel surveyed 1,524 miners and ex-miners in the coal industry during 1958 revealed only 32 cases of pneumoconiosis, not all of whom had worked in New Zealand coal mines. The 1990s This period saw a significant output of publications on non-asbestos occupational respiratory disease, to a large extent due to Professor Neil Pearce of the Centre for Public Health Research at Massey University, together with Dr David Fishwick and Lisa Bradshaw. Over this period occupational asthma was investigated nationally 4 among farmers 5, sawmill workers 6 and aluminium workers 7 ; at the same time respiratory symptoms, lung function and dust levels were measured in the wood industry 8,9, plywood mill workers 10,11, hairdressers 12, mussel openers 13, welders 14,15,16,17,18,19,20,21 and quarry workers In 2000 Dr Jeroen Douwes joined the Centre, accelerating the interest in sawmill workers, wood dust and respiratory effects. 3.1 Occupational Asthma In the Colt Lecture given by Anthony Newman Taylor at the Ninth International Symposium on Inhaled Particles at Cambridge University in , Professor Taylor noted some key points about this disease: asthma is the most prevalent cause in the United Kingdom, and probably in the western world, of respiratory ill health during working life; asthma consists of variable airflow limitation, reversibility and hyperresponsiveness of the airways; asthma can be induced by direct toxic damage to the lining of the airways (irritant inducers) or the RADS phenomenon, or as a result of a specific 24

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